Microscopic colitis презентация

MICROSCOPIC COLITIS
Clinical Definition: chronic, non bloody, watery diarrhea
Occurrence: Middle aged adult
Clinical findings: Normal colonic mucosa on endoscopy or with barium study
Diagnosis made pathologically by biopsy appearance: inflammation but not ulceration

MICROSCOPIC COLITIS
TWO MAIN TYPES
LYMPHOCYTIC
COLLAGENOUS
Seen microscopically as subepithelial lymphocytic infiltrates and no widening of the normal collagen band.
First described in 1976
Thickened sub epithelial bank of collagen 7- 100 micrometers thick (normal is 1-7 micro meters)

MICROSCOPIC COLITIS
EPIDEMIOLOGY
Largest U.S. based study from 1985 - 2001:
Incidence is increased with age
Collagenous colitis much more prevalent in women
Overall prevalence: 103/100,000 persons

MICROSCOPIC COLITIS
EPIDEMIOLOGY
Barcelona, Spain
Both diseases are more common in women
Mean age at onset:
Collagenous 53 years
Lymphocytic 64 years
Other studies performed in Sweden and Iceland have demonstrated an even higher incidence

MICROSCOPIC COLITIS
Generally speaking:
Laboratory findings are nonspecific
Mild anemia, slightly increased ESR in 1/3 of patients
Various antibodies may be found in 50% of patients – RF, ANA, AMA, ANCA, ASCA, Anti-Thyroid Peroxidase

MICROSCOPIC COLITIS
Generally speaking:
Stool studies
Inflammatory markers may be increased:
Eosinophil Protein X
Myeloperoxidase
Tryptase
Calprotectin

MICROSCOPIC COLITIS
HOW DO WE DIAGNOSIS???
Based on biopsy and histology
Severity changes most pronounced in right and transverse colon
Biopsies from the rectosigmoid could miss 40% of cases

MICROSCOPIC COLITIS
May be associated with small bowel disease as well:
Celiac disease
HLA-DR3-DQ2 more frequent in microscopic colitis (predisposes to celiac disease)

MICROSCOPIC COLITIS
May be a systemic disease that is concomitant with autoimmune disorders more common in collagenous (53%) vs. lymphocytic (26%) colitis
Non-erosive arthritis, thyroiditis

MICROSCOPIC COLITIS
Clinical Manifestations and Natural History
Collagenous colitis
vs
Lymphocytic colitis

COLLAGENOUS COLITIS
drugs reported as possible etiology:
Simvastatin
Lansoprazole
Omeprazole
Esomeprazole
Ticlopidine

COLLAGENOUS COLITIS-
Typical presentation is female in their 6th decade; BUT has been reported in children
Onset: Insidious in 58%, sudden 42%
Stool Frequency:
4-9 bowel movements/day in 66%
More than 10/day in 22%
Nocturnal stooling 27%

COLLAGENOUS COLITIS
Variable Associated Symptoms
Nausea
Vague abdominal pain
Fecal urgency
Associated Symptoms
Weight loss – 42%
Abdominal pain – 41%
Fatigue – 24%

COLLAGENOUS COLITIS
Course:
Chronic intermittent- 85%
Chronic continuous- 13%
Single episode- 2%
Long term effects:
General health and lab studies are unaffected
After 10 years-
resolution of diarrhea in 50% pts with anti-inflammatory treatments
persistent symptoms in about 1/3 pts

LYMPHOCYTIC COLITIS
Reported Drug Associations
Ticlopidine
Flutamide
Gold Salts
Lansoprazole
Omeprazole
Esomeprazole
Sertraline

LYMPHOCYTIC COLITIS
CLINICAL COURSE
Long term prognosis: may be more favorable than Collagenous Colitis
After 38 months in a study with 27 patients:
Diarrhea resolved in 93%
Histology normalized in 82%
No progression to collagenous colitis

MICROSCOPIC COLITIS
TREATMENT
Budosenide
Only drug to have proven efficacy (a matter of degree?)
Few studies available with limited number of patients
Probably efficacious at least for short-term

MICROSCOPIC COLITIS
OTHER TREATMENTS
Aminosalicylates/ Sulfasalazine
Cholestyramine
Glucocorticoids (?Lower response rate than budesonide?)
Bismuth subsalicylate: One small study reported with substantial benefits

MICROSCOPIC COLITIS
OTHER THERAPIES
Can try gluten-free diet in “refractory” cases (BUT not necessarily celiac disease)
Metronidazole, octreotide, MTX, 6-MP, Verapamil, Anti-TNFs, Probiotics – some reports, but not enough data to recommend

MICROSCOPIC COLITIS
Natural history
Again few studies available
Roughly, 70% improve/resolve, 25-30% relapse or refractory
No identified increased risk of colorectal cancer